Força muscular e habilidade de locomoção em indivíduos pós-acidente vascular encefálico crônico

ORIGIN

AL RESEAR

CH

DOI: 10.1590/1809-2950/18032126022019

Study developed in the Department of Physical Therapy of Faculdade Ciências Médicas de Minas Gerais (FCM-MG) – Belo Horizonte (MG), Brazil.

1_{Faculdade Ciências Médicas de Minas Gerais (FCM-MG) – Belo Horizonte (MG), Brazil. E-mail: poliana.benfica@gmail.com.}

Orcid: 0000-0003-4611-6386

2_{Faculdade Ciências Médicas de Minas Gerais (FCM-MG) – Belo Horizonte (MG), Brazil. E-mail: emilianeaproza@gmail.com.}

Orcid: 0000-0002-9294-6455

3_{Faculdade Ciências Médicas de Minas Gerais (FCM-MG) – Belo Horizonte (MG), Brazil. E-mail: carlaradiol1@gmail.com.}

Orcid: 0000-0002-2341-8325

4_{Faculdade Ciências Médicas de Minas Gerais (FCM-MG) – Belo Horizonte (MG), Brazil. E-mail: janainepolese@yahoo.com.br.}

Orcid: 0000-0003-3366-1545

166

Corresponding address: Janaíne Cunha Polese – Alameda Ezequiel Dias, 275 – Belo Horizonte (MG), Brazil – Zip Code: 30130-110 – Phone: (31) 99164-5246 – E-mail:

Muscle strength and locomotion ability in individuals

with chronic stroke

Força muscular e habilidade de locomoção em indivíduos pós-acidente vascular encefálico crônico

Fuerza muscular y habilidad de locomoción en individuos post-accidente cerebrovascular crónico

Poliana do Amaral Benfica

_{, Emiliane Aparecida Roza}

_{, Carla Silva Alves Lacerda}

_{, Janaíne Cunha Polese}

ABSTRACT | The objective of this study was to verify if there are differences in the lower-limb muscle strength (LL) and in the locomotion ability among post-stroke patients classified as community or non-community ambulators. A cross-sectional study was conducted in 60 post-chronic stroke subjects, divided into community (n=33) and non-community (n=27) ambulators by gait speed. The muscle strength of seven bilateral muscle groups of LL was evaluated through the modified sphygmomanometer test and locomotion ability through ABILOCO. Descriptive statistics were used to characterize the sample, and Student’s t-test was used for independent samples to compare the two groups of post-stroke individuals. We observed that community ambulators had higher values of muscle strength for most muscle groups of LL (−0.973≥t≥3.189; p≤0.04), and in the locomotion ability (t=−2.841; p=0.006). Community ambulators showed higher LL muscle strength and better locomotion ability compared with non-community ambulators. Physiotherapeutic evaluation of post-stroke individuals should include, besides the measurement of LL muscle strength and its treatment, the measurement of the perception of locomotion ability to analyze the evolution of the patient and the efficacy of the therapeutic behavior.

Keywords | Stroke; Muscle Strength; Locomotion.

RESUMO | O objetivo do estudo foi verificar se existem diferenças na força muscular dos membros inferiores

(MMII) e na habilidade de locomoção de indivíduos pós-acidente vascular encefálico (AVE) crônico, classificados como deambuladores comunitários ou não comunitários. Foi realizado um estudo transversal em 60 indivíduos pós-AVE crônico, divididos em deambuladores comunitários (n=33) e não comunitários (n=27) pela velocidade de marcha. A força muscular de sete grupos musculares bilaterais de MMII foi avaliada por meio do teste do esfigmomanômetro modificado e habilidade de locomoção pelo ABILOCO. Estatísticas descritivas foram utilizadas para caracterizar a amostra, e o teste t de Student para amostras independentes, a fim de comparar os dois grupos de indivíduos pós-AVE. Observou-se que os deambuladores comunitários apresentaram maiores valores de força muscular para a maioria dos grupos musculares de MMII (−0,973≥t≥−3,189; p≤0,04), e na habilidade de locomoção (t=−2,841; p=0,006). Os indivíduos pós-AVE crônico deambuladores comunitários possuem maior força muscular de MMII e mais habilidade de locomoção em comparação aos deambuladores não comunitários. Sugere-se que a avaliação fisioterapêutica de indivíduos pós-AVE inclua, além da mensuração da força muscular de MMII e seu tratamento, a mensuração da percepção da habilidade de locomoção, para análises da evolução do paciente e da eficácia da conduta terapêutica.

Descritores | Acidente Vascular Encefálico; Força

RESUMEN | El objetivo del estudio fue verificar si existen diferencias en la fuerza muscular de los miembros inferiores (MMII) y en la habilidad de locomoción de individuos post-accidente cerebrovascular encefálico (ACV) crónico, clasificados como deambuladores comunitarios o no comunitarios. Se realizó un estudio transversal en 60 individuos post-ACV crónico, divididos en deambuladores comunitarios (n=33) y no comunitarios (n=27) por la velocidad de marcha. La fuerza muscular de siete grupos musculares bilaterales de MMII fue evaluada por medio de la prueba del esfigmomanómetro modificado, y la habilidad de locomoción por el ABILOCO. Las estadísticas descriptivas se utilizaron para caracterizar la muestra, y la prueba t de Student para muestras independientes con el fin de comparar los dos grupos de sujetos

post-ACV. Se observó que los deambuladores comunitarios presentaron mayores valores de fuerza muscular para la mayoría de los grupos musculares de MMII (−0,973≥t≥−3,189; p≤0,04), y en la habilidad de locomoción (t=−2,841; p=0,006). Los individuos post-ACV crónico deambuladores comunitarios poseen mayor fuerza muscular de MMII y más habilidad de locomoción en comparación a los deambuladores no comunitarios. Se sugiere que la evaluación fisioterapéutica de individuos post-ACV incluya, además de la medición de la fuerza muscular de MMII y su tratamiento, la medición de la percepción de la habilidad de locomoción, para análisis de la evolución del paciente y de la eficacia de la conducta terapéutica.

Palabras clave | Accidente Cerebrovascular; Fuerza Muscular; Locomoción.

INTRODUCTION

Although the ability to walk independently is among

the most common goals in the rehabilitation of

post-stroke victims

_{, their recovery is often incomplete and}

insufficient for community ambulation

_{. Among the}

clinical criteria that measure community ambulation,

speed is a measure capable of discriminating categories

of this variable

_{: home ambulation (≤0.39m/s), limited}

community ambulation (0.4 to 0.79m/s) and full

community ambulation (≥0.8m/s)

_.

Lower limb muscle strength is one of the factors that

can influence the gait speed of post-stroke individuals

because it has a significant correlation with this construct

and is therefore related to community ambulation

_.

Another factor that needs to be considered and that

can influence the gait speed and ambulation in the

community of post-stroke individuals is their perception

of locomotion. Self-perception measures are obtained by

the individual’s perception of their performance in the

activities

_{and, even though they are considered susceptible}

to under or overestimation of the actual performance,

they are able to capture an average performance in long

periods of time

_.

Given this context, the objective of this study was to

verify the ability of locomotion and LL muscle strength

in chronic hemiparetic individuals stratified according

to the level of functional performance determined by

the gait speed, considering that muscle strength is one

of the most relevant factors influencing the community

ambulation but that the perception of the locomotion

ability can also be important with better decision making

in the clinical practice.

METHODOLOGY

Cross-sectional study conducted at the Department

of Physical Therapy of Faculdade Ciências Médicas de

Minas Gerais (FCM-MG) and approved by the Research

Ethics Committee of FCM-MG (no. 1.720.245). The

convenience sampling consisted of 60 post-chronic

stroke individuals (33 community ambulators and 27

non-community ambulators). We included individuals

aged over 18 years and time of evolution post-stroke of

at least six months; and excluded those who presented

cognitive alterations identified by the Mini-Mental State

Examination

_{. The sample calculation was carried out a}

posteriori through the G* Power 3.0.10 Program. In this

calculation, the significance level of 0.05 (α=0.05) and

effect size of d=0.7 were considered. The sample included

in this study had a power of 75%.

Before the tests were carried out, the participants were

informed about the objectives of the study and signed

the Informed Consent Form. Next, clinical-demographic

information was collected to characterize the sample.

Participants were classified as community and

non-community ambulators through the 10 meter walk test,

which presents adequate measurement properties for

the post-stroke population

_{. The test was performed}

according to the criteria described by Salbach et al.

_,

were standardized according to the recommendation of

Nascimento et al.

_.

The perception of locomotion performance was

measured by ABILOCO-Brasil

_{, a questionnaire that}

assesses the perception of the locomotion performance of

post-stroke individuals

_{and has adequate measurement}

properties for this population

_{, in addition to a translated}

version adapted for Brazil

_{. The test was applied as an}

interview, in which individuals were asked to estimate

their perceptions of difficulties according to the scale of

responses (“Impossible”=0, and “Possible”=1)

_.

To evaluate the lower limb muscle strength, the

modified sphygmomanometer test (MST)

_was

used, which provides objective measurements and has

a low price

_{. In addition, it also presents adequate}

measurement properties for post-stroke individuals

_.

MST with pocket adaptation was used to measure the

isometric muscle strength of seven muscle groups of the

bilateral lower limbs (hip flexors, extensors and abductors,

knee flexors and extensors, and ankle dorsiflexors and

plantar flexors). A mobile aneroid sphygmomanometer

of the brand Tycos (WelchAllyn Inc., NY, USA, model

DS-44), already calibrated by the manufacturer, was used.

The adaptation took place by the removal of the inflatable

part from inside the cuff of the sphygmomanometer,

which was folded in three parts and placed inside a bag

of cotton cloth

_{. The positions were standardized and}

followed the descriptions of Souza et al

_{. After the}

familiarization, a maximum contraction of each muscle

group was performed, with a duration of five seconds and

a rest period of 20 seconds between the measurements,

which were initiated by the non-paretic side and had

verbal stimulation

_.

Descriptive statistics were performed to characterize

the sample. The Student’s t-test for independent samples

was applied to compare the two groups and to verify if

there are differences regarding the perception of the

locomotion performance and the lower limb muscle

strength. The statistical package used for all analyses was

SPSS for the Windows version 18.0 (SPSS Inc., Chicago,

IL, USA), considering the significance level of α=0.05.

RESULTS

Sixty post-stroke subjects – 33 community ambulators

and 27 non-community ambulators – were evaluated

in the study. Table 1 shows the clinical-demographic

characteristics of the total sample and the separate

groups.

Table 1. Clinical and demographic characteristics of the participants (mean and standard deviation or absolute number and percentage)

Characteristics Total Sample _(n=60)

Groups Community ambulators (n=33) Non-community ambulators (n=27) Sex Female Male 26 (43.3%)34 (56.7%) 22 (66.7%)11 (33.3%) 15 (55.5%)12 (44.5%) Age (years) 59.0 (15.7) 54.4 (16.0) 64.4 (13.8)

Stroke evolution time (months) 62.2 (47.8) 49.3 (37.8) 77.9 (54.5)

Stroke Type Ischemic Hemorrhagic Both 41 (68.3%) 11 (18.3%) 4 (6.7%) 20 (68.9%) 8 (27.5%) 1 (3.6%) 21 (77.6%) 3 (11.2%) 3 (11.2%)

Table 2 shows the comparison between the groups

of community and non-community ambulators in

relation to the muscle strength assessed by MST

and the locomotion ability evaluated by ABILOCO.

The Student’s t-test showed a statistically significant

difference between the groups regarding the muscle

strength of eight muscle groups – hip flexor and

abductors, and knee flexors on both paretic and

non-paretic sides; paretic knee extensors and plantar

flexors – (−0.973≥t≥−3.189; p≤0.04), and in the

perception of locomotion performance (t=−2.841;

p=0.006), with non-community ambulators presenting

higher values in the muscle strength of these muscles

and in the perception of locomotion performance.

Table 2. Comparison between the groups studied in relation to lower limb muscle strength assessed by MST and the perception of locomotion performance assessed by ABILOCO

Variables Community ambulators (n=33)_{Mean (SD)} Non-community ambulators (n=27)_{Mean (SD)} p; t Mean difference (95%CI)

P hip flexors 162.9 (53.0) 133.7 (36.4) 0.018; −2.427 −58.3 (−53.2 to −5.1) NP hip flexors 206.3 (47.1) 162.7 (58.9) 0.002; −3.189 −87.2 (−71.0 to −16.2) P hip extensors 211.27 (62.2) 184.2 (60.0) 0.094; −1.702 −54.1 (−58.9 to 4.8) NP hip extensors 242.8 (49.5) 228.7 (56.5) 0.307; −1.030 −28.2 (−41.5 to 13.3) P hip abductors 131.1 (48.4) 101.6 (30.0) 0.008; −2.762 −59.0 (−50.9 to −8.1) NP hip abductors 154.4 (29.6) 135.4 (38.4) 0.035; −2.165 −38.0 (−36.6 to −1.4) P knee flexors 157.7 (71.8) 112.7 (61.2%) 0.012; −2.581 −90.0 (−79.9 to −10.1) NP knee flexors 227.7 (46.4) 197.7 (64.1) 0.040; −2.097 −59.9 (−58.6 to −1.3) P knee extensors 236.7 (54.2) 194.0 (56.6) 0.004; −2.969 −85.2 (−71.3 to −13.9) NP knee extensors 259.52 (42.6) 242.37 (51.4) 0.163; −1.413 −34.3 (−41.4 to 7.1) P dorsiflexors 134.3 (78.8) 104.7 (47.5) 0.078; −1.795 −59.3 (62.7 to 3.4) NP dorsiflexors 193.1 (46.9) 169.5 (60.2) 0.094; −1.705 −47.1 (−51.2 to 4.1) P plantar flexors 153.7 (82.7) 105.0 (45.4) 0.006; −2.886 −97.2 (−82.4 to −14.8) P plantar flexors 198.5 (53.6) 82.2 (72.4) 0.336; −0.973 v32.6 (−50.0 to 17.4) ABILOCO 3.72 (2.06) 2.45 (1.38) 0.006; −2.841 −2.6 (−2.2 to −0.4)

95%CI: 95% confidence interval; SD: standard deviation; P: paretic; NP: non-paretic.

DISCUSSION

The relationship between lower limb muscle

strength and gait speed is already well established

in the literature

_{, and, in this study, most muscle}

groups presented statistically higher values in the

group of community ambulators compared with

non-community ambulators. van de Port et al.

_{and Lee et al.}

investigated the relationship between community

ambulation and factors that determine the ambulation

ability in post-chronic stroke individuals, considering the

different categories of community ambulation through

four levels of self-reported unsupervised mobility

_{. The}

results of these studies showed that the gait speed and

the LL muscle strength were significantly related to the

ambulation in the community

_{, that is, even though}

not using the same classification of the community

ambulation of this study, gait speed and muscle strength

were evaluated and were positively related to community

ambulation, corroborating with the results of this study.

Although most muscle groups showed differences

between community and non-community ambulators, six

muscle groups were not statistically different from each

other. Aguiar et al.

_{and Souza et al.}

_{, who evaluated}

the MST measurement properties (test-retest and

inter-rater validity and reliability) in the subacute and

chronic post-stroke population, respectively, presented

low correlation results for the non-paretic plantar flexors

(test-retest

_{and inter-rater}

_{reliability) and non-paretic}

dorsiflexors (test-retest

_{reliability). The authors explained}

this fact through problems that occurred during the

evaluation, which may also have occurred in this study. For

non-paretic plantar flexors, the difference in resistance

provided by the rater during assessment, associated with

the short lever arm of the foot and with the great strength

exerted by the plantar flexors, may have required the

rater to apply greater strength to maintain isometric

contraction

_{. For dorsiflexors, the difficulty of stabilizing}

the equipment in a small area may have been an obstacle

to a correct evaluation

_{. For the other muscle groups, a}

possible explanation would also be the problems that

occurred during the assessment: for bilateral hip extensors

and non-paretic knee extensors, the difficulty in stabilizing

the limb in isometry during muscle strength assessment

may have altered the measurements because they are

muscle groups capable of generating a lot of strength

_.

Regarding the locomotion ability, community

ambulators seem to have perceived a better locomotion

performance than non-community ambulators. It seems

obvious to think that individuals with higher gait speed

have better performance in locomotion; however, no

studies on the differences in the locomotion ability

between these two groups were found. Despite this, it is

very important to consider the self-perception measures,

since they are capable of assessing the individual’s actual

performance

_{, which is linked to what they accomplish}

in their true life context

_{. In addition, it is important}

to consider customer-centric practice, which recognizes

the role of the patient in clinical decision making

_.

Thus, the individual who can identify limitations on the

performance of their locomotion may request the physical

therapeutic behavior to be aimed at the improvement of

this limitation.

This study presents some limitations. The convenience

sampling provided results that cannot be generalized for

individuals with characteristics different from those of the

individuals evaluated. Moreover, due to the methodology

and design used, it is not possible to establish cause and

effect relationships with the presented results.

CONCLUSION

Community ambulators have greater muscle strength

in most muscle groups of LL and better locomotion

ability compared with non-community ambulators. In

this way, physical therapeutic evaluation should include,

besides the measurement of the LL muscle strength

and its treatment, the quantification of the locomotion

perception, which could help the analysis of the evolution

of post-stroke patients and the efficacy of the therapeutic

approach used to this end.

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